Ahn et al.

Journal of Foot and Ankle Research (2016) 9:38

DOI 10.1186/s13047-016-0171-4

RESEARCH

Open Access

Ultrasonographic examination of plantar

fasciitis: a comparison of patient positions
during examination
Jae Hoon Ahn1, Choong Woo Lee2, ChanJoo Park2 and Yoon-Chung Kim2*

Abstract
Background: Musculoskeletal ultrasound is a non-invasive and low-cost modality for real-time visualisation of
the plantar fascia. Ultrasound examination for plantar fasciitis is generally performed with the patient in a prone
position, although the rational for using a prone position has not been validated. The aim of the study was to
investigate if ultrasound examination in a supine position, which is more comfortable than the prone position,
is valid.
Methods: We conducted a prospective study of 30 participants with plantar fasciitis, 8 men (27 %) and 22 women
(73 %), with a mean age of 53.9 12.6 (range, 32 to 77) years, and an equal distribution of left and right feet.
The plantar heel was divided into three portions for ultrasound examination: medial, central and lateral. Two
measurements of plantar fascia thickness were obtained for each portion, with participants in 2 positions (supine
and prone) and for 2 ankle postures (neutral and 15 of plantarflexion). Mean measurements of plantar fascia
thickness were compared between the two positions (Wilcoxon signed rank tests for non-normally distributed
data and paired t-tests for normally distributed data). Participants were asked to report their preferred position for
examination, supine or prone.
Results: The measured thickness was comparable for both supine and prone positions, for both ankle postures,
neutral and 15 of plantarflexion (p > 0.05). A specific self-reported preferred position was not identified.
Conclusions: Ultrasound examination of plantar fasciitis can be performed in the supine position without any
significant difference in measurement compared to examination in the conventional prone position.
Trial registration: The Catholic Medical Center Office of Human Research Protection Program (CMC-OHRP)/
Institutional Review Board approved the current study (Approval No. KC12DISI0338), and all participants provided
their written informed consent for participation and publication.
Keywords: Plantar fasciitis, Ultrasound, Supine position, Prone position

Background
Plantar fasciitis is the most common cause of chronic heel
pain, accounting for 15 % of all foot complaints among
out-patients in general orthopaedic clinics [15]. Histologically, the plantar fascia is comprised of a common tendon
aponeurosis for a superficial layer of intrinsic plantar foot
muscles, rather than being a true fascial layer.
* Correspondence: cruzinbooo@catholic.ac.kr
2
Department of Orthopaedic Surgery, St. Vincents Hospital, College of
Medicine, The Catholic University of Korea, Jungbu-daero 93, Paldal-gu,
Suwon-si, Gyeonggi-do 16247, Republic of Korea
Full list of author information is available at the end of the article

As an aponeurosis, the plantar fascia is easily visualised

by ultrasound imaging, similar to superficial tendons.
Musculoskeletal ultrasound is considered to be a useful
diagnostic modality for plantar fasciitis, providing realtime and dynamic visualisation, while being non-invasive,
inexpensive and radiation-free [1, 5, 6]. Generally, ultrasound examination of plantar fasciitis is performed with
the patient in a prone position. However, no theoretical
background or validation studies have been conducted to
confirm the most appropriate position for ultrasound
examination of plantar fasciitis. During ultrasound examination for plantar fasciitis, the authors have found that

2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Ahn et al. Journal of Foot and Ankle Research (2016) 9:38

the prone position is relatively time-consuming because

the patient has to change position after sitting on the
table. In addition, the supine position appears to be more
comfortable compared to the prone position since the
chest and abdomen are not compressed as they are in the
prone position.
The aim of the study was to investigate the concurrent
validity (accuracy) of conducting an ultrasound examination of the plantar fascia in a supine position. If found
to be valid, the supine position may be of benefit for reducing examination time and improving patient comfort
during examination.

Methods
Our methods and procedures were approved by the
Catholic Medical Center Office of Human Research Protection Program (CMC-OHRP)/Institutional Review
Board (Approval No. KC12DISI0338), and all participants provided written informed consent for participation and publication of the research findings.
The study sample was comprised of 30 participants
who underwent ultrasound examination for plantar fasciitis in our clinic, between June 2012 and January 2013.
Inclusion criteria were: (i) chronic heel pain > 3 months;
(ii) presence of morning pain characteristic of plantar
fasciitis; (iii) confirmation of heel pad tenderness on
physical examination; and (iv) thickness of the plantar
fascia > 4.0 mm on ultrasound imaging. This cut-off thickness criterion was based on current evidence that a plantar fascia thickness > 4.0 mm on ultrasound imaging is
consistent with plantar fasciitis [1, 69]. Exclusion criteria
were: systematic inflammatory arthritis, diabetes mellitus
and long-standing neuromuscular disease. Our sample included 8 men (27 %) and 22 women (73 %), with a mean
age of 53.9 12.6 (range, 32 to 77) years, with an equal
distribution of right and left presentation of plantar fasciitis (n = 15 each). Prior to ultrasound imaging at the first
clinic visit, duration of symptoms and the Visual Analogue
Scale pain scores were recorded. Following the ultrasound
examination, participants were asked to state their preferred examination position, supine or prone.
The ultrasound examination was performed using a
Philips HD11-XE Ultrasound System (Koninklijke Philips
Electronics N.V., Amsterdam, the Netherlands), fitted with
a 12-MHz linear-array transducer. For assessment, the
plantar heel was divided into medial, central and lateral
portions. Considering that the measured thickness of
plantar fascia may be influenced by the ankle posture,
measurements for each portion of the plantar heel were
obtained in two ankle joint postures, neutral and 15 of
plantarflexion. Each measurement was repeated twice, for
the two ankle postures and for the two positions, with the
mean of the two measurements used to compare measurements obtained in supine and in prone.

Page 2 of 5

All measurements of plantar fascia thickness were obtained at the same reference point, where the fascia
crosses the anterior most aspect of the inferior border of
the calcaneus [1]. The vertical thickness of the plantar
fascia was measured as shown in Fig. 1, with confirmation that all participants had a thickness > 4.0 mm. All
ultrasound examinations and measurements were performed by one sonographer. The sonographer (Y-CK)
was a second-year fellow in a foot and ankle subspecialty
and a certified medical doctor from the national board
of orthopedic surgery. In addition, the sonographer had
finished basic and advanced musculoskeletal ultrasound
courses, which were hosted by the national academic society of foot and ankle ultrasound imaging. During our
study, every measurement was double-checked by the
senior author (JHA) who is an executive member of the
national academic society of foot and ankle ultrasound
imaging. The senior author has more than 10 years of
experience in performing ultrasound examination of
plantar fasciitis.
All data were analysed using SPSS version 18.0 (SPSS
Inc. Chicago, Illinois). Paired t-tests were used for normally distributed data and Wilcoxon signed rank tests
were used for non-normally distributed data to compare
the supine and prone position groups. Means and standard deviations were computed for normally distributed
variables, whereas medians and the interquartile range
(IQR; 25th-75th) were used for non-normally distributed
data. Statistical significance was accepted for p values
of < 0.05.

Results
The mean duration of symptoms prior to the clinic visit
was 8.4 9.07 months (range 2 to 48 months), with a
mean Visual Analogue Scale pain score of 6.1 1.67
(range 3 to 9). With regard to positioning for the

Fig. 1 The vertical thickness of the plantar fascia was measured at a

standard reference point (white arrow) where the fascia crosses the
anterior most aspect of the inferior border of the calcaneus

Ahn et al. Journal of Foot and Ankle Research (2016) 9:38

ultrasound examination, 14 participants (47 %) preferred

the supine position and 13 (43 %) the prone position,
with the remaining 3 participants (10 %) not having a
preference. Participants provided the following reasons
for preferring the supine position for the examination:
(i) it facilitated communication with the examiner during the ultrasound examination and (ii) it provided the
possibility of seeing abnormal findings on the monitor;
combined with real-time explanation regarding the status of their painful heel.
The measured thickness of the plantar fascia in both
supine and prone positions, with the ankle in a neutral
posture, is shown in Fig. 2, with no between-position differences in measurements across all three portions of
the plantar heel (p > 0.05; Table 1). Comparable results
were also obtained for measurements between supine
and prone positions, with the ankle posture of 15 plantarflexion (p > 0.05; Table 2).

Discussion
The plantar fascia is easily visualised by ultrasound imaging because it is a superficial structure. Sabir et al. [1]
suggested that ultrasound imaging could be as valuable

Page 3 of 5

Table 1 Comparison of plantar fascia thickness between supine

and prone positions with the ankle in a neutral posture
Portion of plantar heel

p value

Position
Supine

Prone

Medial

5.0 [4.5; 6.0]

5.1 [4.2; 6.1]

0.973a

Central

5.1 [4.1; 5.6]

5.0 [4.2; 6.1]

0.620a

Lateral

4.9 1.0

4.8 1.1

0.600b

Measured thickness (mm) values are presented as median [interquartile range;

25th75th] for non-normally distributed data or mean standard deviation for
normally distributed data
p values obtained from Wilcoxon signed rank test a or paired t-test b
Significance was accepted for p values of < 0.05

as magnetic resonance image for the diagnosis of plantar

fasciitis. As the ultrasound examination is readily available, it is increasingly being used for the diagnosis of
plantar fasciitis [6, 9].
The usefulness of ultrasound imaging is often limited
by examiner-dependent error [10]. However, previous
studies have provided evidence of the reproducibility of
measurements of plantar fascia thickness by ultrasound,
with high intra-and inter-observer reliability [11, 12]. In
our study, all ultrasound measurements were performed
by one examiner to eliminate examiner-dependent variability in measurement.
In the majority of studies reported to date, ultrasound
examination of plantar fasciitis has been performed with
the patient in a prone position, with the foot hanging
freely over the end of the examination bed at an angle of
90 relative to the leg [1, 5, 6, 9, 13]. However, evidence
to support this position is lacking, which prompted us to
undertake our investigation. In this comparative study,
we investigated whether there were any significant differences in ultrasound measurements of plantar fascia
thickness when participants were placed in a supine or a
prone position.
Our findings provide evidence that measurements obtained in both the supine and prone position were similar,
with differences in measurement of 0.1 mm in the medial,
central and lateral portions of the plantar fascia with the
ankle in a neutral posture, and no more than 0.2 mm for

Table 2 Comparison of plantar fascia thickness between supine

and prone positions with the ankle in a 15 plantarflexion posture
Portion of plantar heel

Fig. 2 Comparison of measurements of plantar fascia thickness

obtained in supine and in prone positions for a representative
54-year-old woman, with the ankle in a neutral posture. A thickness of
7.0 mm was obtained in the supine position (a); compared to 7.1 mm
in the prone position (b)

p value

Position
Supine

Prone

Medial

5.0 [4.3; 5.8]

5.0 [4.4; 6.0]

0.052

Central

4.7 [4.2; 5.4]

4.9 [4.2; 5.4]

0.062

Lateral

4.5 [4.1; 5.0]

4.6 [4.1; 5.1]

0.674

Measured thickness (mm) values are presented as median [interquartile range;

25th75th] as data was not normally distributed

p values were obtained from Wilcoxon signed rank test

Significance was accepted for p values of < 0.05

Ahn et al. Journal of Foot and Ankle Research (2016) 9:38

the central portion and 0.1 mm for the lateral portion with
the ankle posture of 15 plantarflexion. Moreover, a preferred position was not definitively identified by participants, although participants did report viewing of the
ultrasound images as a benefit of examination in the supine position. However, some participants reported feeling
awkward and nervous facing the examiner when the
examination was performed in the supine position.
Based on these results, we propose that the either a
supine or prone position can effectively be used for the
ultrasound examination of plantar fasciitis, with the position not being a significant influence on the accuracy of
measurements. Therefore, the position for ultrasound
examination can be selected in a patient-specific way
without concern for the accuracy of the measurements.
In particular, if the patient is unable to or if they feel uncomfortable being requested to adopt the prone position,
the ultrasound examination of plantar fasciitis can be
performed in the supine position knowing that the result
will be the same.
There are three limitations of this study that should be
acknowledged. Firstly, our study sample was relatively
small (n = 30), with a predominance of women (73 %).
Secondly, only two measurements of plantar fascia thickness were obtained for each portion of the plantar heel,
with measurements obtained during the same assessment session. Therefore, intra-observer reliability was
not formally addressed. Thirdly, the sonographer could
not perform all measurements in a blinded manner because the out-patient clinic examination was performed
simultaneously with the ultrasound examination. With
these limitations in mind, we consider our study as providing preliminary evidence and justification for larger
studies, with a blinded assessor (or preferably blinded
assessors), to confirm the equivalence of the two patient
positions, supine and prone, for ultrasound examination
of plantar fasciitis.

Conclusions
We found no difference in the ultrasound measurement
of plantar fascia thickness in our sample of participants
with plantar fasciitis when the examination was performed in the prone or the supine position. In addition,
participants did not have a clear preference for whether
they preferred to be examined in the prone or supine
positions. Therefore, ultrasound examination of plantar fasciitis can be performed with patients in either a
supine or a prone position, according to patients preference, without concern about the accuracy of the
measurement.
Abbreviations
CMC-OHRP: The catholic medical center office of human research protection
program

Page 4 of 5

Acknowledgement
All authors thank to Dr. Sei Won Kim for data analysis with statistical
consultation. We would also like to thank Editage (www.editage.co.kr) for
English language editing.
Funding
All authors received no financial support for the research, authorship, and/or
publication of this article.
Availability of data and material
All data analysed during this study are included in this published article. The
datasets during and/or analysed during the current study available from the
corresponding author on reasonable request.
Authors contributions
JHA and Y-CK participated in the design of the study. Y-CK performed all
ultrasound examinations and measurements. JHA double-checked every
ultrasound measurement simultaneously. CWL, CJP and Y-CK collected and
interpreted the participant data. JHA and Y-CK conducted data analysis.
JHA wrote the first draft and Y-CK performed the critical review and revision.
All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
All participants provided written informed consent for publication.
Ethics approval and consent to participate
Our methods and procedures were approved by the Catholic Medical Center
Office of Human Research Protection Program (CMC-OHRP)/Institutional
Review Board (Approval No. KC12DISI0338), and all participants provided
written informed consent for participation.
Author details
1
Department of Orthopaedic Surgery, Seoul St. Marys Hospital, College of
Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu,
Seoul 06591, Republic of Korea. 2Department of Orthopaedic Surgery, St.
Vincents Hospital, College of Medicine, The Catholic University of Korea,
Jungbu-daero 93, Paldal-gu, Suwon-si, Gyeonggi-do 16247, Republic of
Korea.
Received: 8 April 2016 Accepted: 13 September 2016

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